Risk factors associated with pressure ulcer development in critically ill traumatic spinal cord injury patients

The effect of vasopressor agents on pressure injury development in intensive care patients

BACKGROUND

Vasopressors are life-saving agents that increase mean arterial pressure. The pharmacodynamic features of these agents and previous studies suggest that vasopressors may be an essential risk factor in developing pressure injuries.

OBJECTIVE

This study aimed to examine the effect of vasopressors in medical-surgical intensive care patients on pressure injury development.

DESIGN AND SETTINGS

This retrospective and correlational study was conducted between March 2021- May 2022. The electronic patient data were obtained from 148 surgical and medical patients exposed to vasopressor agents in the intensive care unit. Data on patients' demographic and clinical characteristics were evaluated using descriptive statistical methods (number, percentage, mean, standard deviation). Logistic regression modelling was used to assess independent relationships with pressure injury risk; results are reported as odds ratios (OR) and 95% confidence intervals (CI).

RESULTS

All patients were given norepinephrine agents, and dopamine infusion secondary to norepinephrine was found in only 28.3 % of patients (n = 42). Pressure injury incidence was 43.2 % (n = 64). Duration of norepinephrine infusion was recognized as an independent risk factor for ICU-acquired pressure injury development (OR 1.22, 95 % CI 1.11-1.35), while a medical admission diagnosis (instead of surgical) was protective against pressure injury risk (OR 0.24, 95 % CI 0.10-0.59).

CONCLUSION

This study indicated that duration of norepinephrine infusion is a significant risk factor for pressure injury development.

IMPLICATIONS FOR CLINICAL PRACTICE

Although norepinephrine use cannot be avoided entirely, its administration may be an early warning for nurses to increase pressure injury prevention strategies. Skin evaluation should be performed more frequently, and preventive strategies should be implemented meticulously. This study was registered on clincialtrials.gov (Identifier: NCT06163352).

Decreasing pressure injuries and acute care length of stay in patients with acute traumatic spinal cord injury

OBJECTIVES

Identifying factors associated with the occurrence of pressure injuries (PI) during acute care and with longer length of stay (LOS), focusing on modifiable factors that can be addressed and optimized by the acute rehabilitation team.

DESIGN

Prospective cohort study.

SETTING

A single Level-1 trauma center specialized in SCI care.

PARTICIPANTS

A cohort of 301 patients with acute TSCI was studied.

OUTCOME MEASURES

The primary outcome was the occurrence of PI during acute care stay. The secondary outcome was acute care LOS. Bivariate and multivariate logistic or linear regression analyses were performed to determine the association between non-modifiable factors and outcomes (PI of any stage and acute LOS), whereas bivariate and hierarchical multivariate logistic or linear regression analyses were used for modifiable factors.

RESULTS

When controlling for the level and severity of the TSCI, the occurrence of pneumonia (OR = 2.1, CI = 1.1-4.1) was significantly associated with the occurrence of PI. When controlling for the level and severity of the TSCI, the occurrence of medical complications (PI, urinary tract infection and pneumonia) and lesser daily therapy resulted in significantly longer acute care LOS (P < .001).

CONCLUSIONS

Prevention of PI occurrence and the optimization of the acute care LOS represent crucial challenges of the acute rehabilitation team, as they are significantly associated with higher functional outcomes. Patients who develop pneumonia may benefit from more aggressive prevention strategies to reduce PI occurrence. Systematic protocols for the prevention of complications as well as greater volume of therapy interventions should be considered to optimize the acute care LOS.

Risk Factors for Pressure Injury Development Among Critical Care Patients

Identification of the appropriate pressure injury (PI) risk factors is the first step in successful PI prevention. Measuring PI risk through formalized PI risk assessment is an essential component of any PI prevention program. Major PI risk factors identified in the empirical literature in the critical care population include age, diabetes, hypotension, mobility, prolonged intensive care unit admission, mechanical ventilation and vasopressor administration. Future risk assessment using sophisticated data analytics available in the electronic medical record may result in earlier, targeted PI prevention and will improve our understanding of risk factors that may contribute to unavoidable PIs.

Pressure Injuries in Critical Care Patients: A Conceptual Schema

GENERAL PURPOSE

To outline a conceptual schema describing the relationships among the empirically supported risk factors, the etiologic factors, and the mitigating measures that influence pressure injury (PI) development in the critical care population.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will: 1. Choose a static intrinsic factor that increases the risk for the development of PI. 2. List several dynamic intrinsic risk factors for developing a PI. 3. Identify dynamic extrinsic risk factors that may predispose a patient to developing a PI. 4. Explain the pathophysiology of PI development.

Angiosomal Vascular Occlusions, Deep-Tissue Pressure Injuries, and Competing Theories: A Case Report

ABSTRACT

Compression of the soft tissue between a support surface and a bony prominence has long been the accepted primary mechanism of pressure injury (PrI) formation, with the belief that said compression leads to capillary occlusion, ischemia, and tissue necrosis. This explanation presupposes an "outside-in" pathophysiologic process of tissue damage originating at the local capillary level. Despite advances in prevention protocols, there remains a stubbornly consistent incidence of severe PrIs including deep-tissue injuries, the latter usually evolving into stage 4 PrIs with exposed bone or tendon. This article presents just such a perioperative case with the aim of providing further evidence that these more severe PrIs may result from ischemic insults of a named vessel within specific vascular territories (labeled as angiosomes). Pressure is indeed a factor in the formation of severe PrIs, but these authors postulate that the occlusion occurred at the level of a named artery proximal to the lesion. This vascular event was likely attributable to low mean arterial pressure. The authors suggest that the terminology proposed three decades ago to call both deep-tissue injuries and stage 4 PrIs "vascular occlusion pressure injuries" should be the topic of further research and expert consensus.

Feedback improves compliance of pressure relief activities in wheelchair users with spinal cord injury

STUDY DESIGN

Prospective cross-sectional pre-post pilot study.

OBJECTIVES

This pilot study aimed to evaluate the potential for improving pressure relief behaviour in wheelchair users with spinal cord injury (SCI) using a novel feedback system based on textile pressure sensor technology.

SETTING

In- and out-patient clinic of the Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland.

METHODS

Nine wheelchair users with SCI (3 females, 50 ± 12 years of age, 2 tetra- and 7 paraplegics) were equipped with a feedback system (sensomativewheelchair) for three continuous weeks. The system consists of a textile pressure mat and a mobile smartphone application that reminds participants to perform missing pressure reliefs during regular and unobserved wheelchair usage in a customized manner. Pressure reliefs were detected using a subject-specific random forest classifier. Improvements of relief quality, duration and frequency were analysed by comparing week 1 (baseline) with no feedback, i.e., only pressure data recorded, against week 2 (with feedback). Carry-over effects of improved relief behaviour were studied in week 3 (no feedback, pressure data only recorded).

RESULTS

All participants increased their relief frequency and performed in median 82% (IQRs: 55%-99%) of the required reliefs while using the feedback system, whereas the median relief frequency was only 11% (IQRs: 10%-31%) during the baseline condition. Every participant who did not perform reliefs of sufficient duration (based on the recommendations of the therapist) during week 1 showed a significant improvement while using the feedback system.

CONCLUSION

Subject-specific feedback using the novel feedback system may have the potential for improving the regularity of an individual's relief activities, and may ultimately be an instrument for reducing the risk of developing pressure ulcers.

A Multicenter, Comparative Study of Two Pressure-Redistribution Mattresses with Repositioning Intervals for Critical Care Patients

OBJECTIVE

To compare the effectiveness of two protocols for preventing pressure injuries (PIs) in Chinese hospitals.

DESIGN AND SETTING

A multicenter, open-label, comparative study conducted in seven Chinese acute care hospitals.

PATIENTS AND INTERVENTION

In total, 1,654 eligible patients were identified, and 1,204 were enrolled in the study. Enrolled patients were randomly assigned into the trial group (4-hour repositioning combined with a viscoelastic foam mattress; n = 602) or the control group (2-hour repositioning combined with a powered air pressure redistribution mattress; n = 602). Participants received their respective protocols until they were discharged, died, or for at least 7 days.

MAIN OUTCOME MEASURES

The incidence of PIs, Braden Scale scores, and the time to development of PIs.

MAIN RESULTS

Ultimately, 596 trial group patients and 598 control group patients were analyzed. Thirteen patients had single new stage 2 or worse PIs. The total incidence of PIs was 1.1%. The difference between the two groups was significant (0.3% vs 1.8%). However, the difference between the groups' Braden Scale score median during the intervention was not significant (13 vs 13.5).

CONCLUSIONS

The 4-hour repositioning interval combined with a viscoelastic foam mattress did not increase PI incidence or risk. These findings could help providers select the right pressure redistribution mattresses and repositioning intervals for critical care patients.

Surgical reconstruction of pressure ulcers in spinal cord injury individuals: A single- or two-stage approach?

INTRODUCTION

There are two surgical approaches to reconstruct a pressure ulcer (PU): one-stage reconstruction or two-stage reconstruction. One stage reconstruction consists of surgical debridement and flap reconstruction during one operation. Two-stage surgery consist of a surgical debridement and a final reconstruction in two different sessions, with approximately six weeks between both sessions.

OBJECTIVE

The aim of this study was to compare the results of single stage surgery and two-stage surgery on the PU recurrence rate and other important post operative complications.

METHOD

A retrospective, comparative study in Spinal Cord Injured (SCI) individuals with a single- or two stage surgical reconstruction between 2005 and 2016 was designed. A total of 81 records were included for analysis.

RESULTS

The primary outcome, the difference in occurrence of a recurrent PU in the reconstructed area (33.3% versus 31.6%), is not statistically significant between one-and two-stages reconstruction. Also, the mean duration to develop a recurrent PU between both surgical reconstructions is not statistically significant. Other surgical complications in the reconstructed area like wound hematoma, hemorrhage, seroma or (partial) flap failure did not differ significantly between both groups, apart and in total. We calculated the additional costs in case of a two-stage approach compared with a single-stage reconstruction at EUR 16,362.

CONCLUSIONS

There are no statistical significant differences in PU recurrence rate or other post operative complications between SCI patients who have undergone one- or two stage PU reconstructive surgery. The most obvious choice for a one-stage approach in case of PU reconstructive surgery has great positive implications for the patient, family, health care providers and the health care system.

Predictors of pressure injury development in critically ill adults: A retrospective cohort study

OBJECTIVE

The purpose of this research was to identify predictors of pressure injury, using data from the electronic health records of critically ill adults.

METHODOLOGY

A retrospective cohort study was conducted using logistic regression models to examine risk factors adjusted for age, gender, race/ethnicity and length of stay.

SETTING

The study cohort included 1587 adults in intensive care units within an urban academic medical centre.

MAIN OUTCOME MEASURES

The presence or absence of a hospital-acquired pressure injury was determined during monthly skin integrity prevalence surveys. All pressure injuries were independently confirmed by two Certified Wound Care Nurses.

RESULTS

Eighty-one (5.1%) of the 1587 cohort patients developed pressure injuries. After adjusting for confounders, the clinical variables associated with pressure injury development included mean arterial pressure <60 mmHg and lowest Total Braden score up to two weeks prior to the date of HAPI development or date of prevalence survey for the comparison group.

CONCLUSIONS

This study provides a more comprehensive understanding about pressure injury risk in critically ill adults, identifying extrinsic and intrinsic factors associated with pressure injury development. Prospective multisite studies are needed to further examine these potential contributors to pressure injury development within the context of adherence to prevention interventions.

The prevalence, incidence, and associated factors of pressure injuries among immobile inpatients: A multicentre, cross-sectional, exploratory descriptive study in China

The aim of this study was to assess the prevalence, incidence, and the associated factors of pressure injuries (PIs) among immobile hospitalised patients in China. Being immobile during hospitalisation put these patients at a higher risk of PIs. There is little literature about pressure injury (PI) prevalence or PI incidence in immobile hospitalised patients in hospitals in China. This was a multicentre, cross-sectional, exploratory descriptive study. A total of 23 985 immobile patients were recruited from 25 general hospitals in six provinces of China from November 1, 2015 to March 18, 2016. Information was collected on demographic characteristics, physical assessment information, and treatment and nursing care measures. The PI period prevalence was 3.38%, and the PI cumulative incidence was 1.23%. Most PIs (84.03%) were Stage 1 or Stage 2. A total of 48.22% of PIs occurred in the sacrum or heel region. In the multivariate analysis, the following factors were associated with higher PI prevalence: age, gender, length of immobility, type of hospital, modified Braden Scale score, urinary incontinence, faecal incontinence, low serum albumin, the usage of fixation or restraint devices, and patient's discharge diagnosis (lower limb fracture, malnutrition, and spinal cord injury). PI prevalence for immobile hospitalised patients in the study was lower than those reported in literature. However, because of the large population in China, the number of patients who suffer with PIs can be very high. The relating factors of higher PI prevalence identified in this study were consistent with current literature. Patients with a higher number of these associated factors should be monitored more closely, and preventative measures should be taken to prevent PI occurrence in high-risk populations.

Outcome analyses of a multimodal treatment approach for deep pressure ulcers in spinal cord injuries: a retrospective cohort study

STUDY DESIGN

Retrospective observational cohort study.

OBJECTIVES

To describe outcomes, risk factors for complications, and relapse rates associated with the multimodal treatment approach for deep pressure ulcers (PUs) grade IV for the ischium, trochanter major, and sacral regions of patients with traumatic and non-traumatic spinal cord injury (SCI).

SETTING

The settings comprised two spinal cord units within a maximum care hospital. The treatment of all patients followed the modified interdisciplinary "Basler treatment concept".

METHODS

We included all individuals with SCI with a first occurrence of PU grade IV in the buttocks area between August 2008 and December 2012 inclusive, with a maximum follow-up of 3 years. Descriptive, univariate, and bivariate analyses were undertaken, as were group comparisons.

RESULTS

In 47 patients aged 18-87 years (mean age: 51 years) a total of 63 fasciocutaneous and myocutaneous flaps were performed. Wound healing was complete after a mean of 34 days (SD = 21). Postoperative mobilisation in a wheelchair was performed after a mean of 46 days (SD = 24). Delayed healing was reported in 18 patients (38%), and revision surgery was necessary in five patients (11%). ASIA impairment scale (AIS) A (p = .001), and male gender (p = .001) were identified as risk factors for delayed wound healing and prolonged inpatient stay. Treatment-associated pneumonia occurred in four cases (11% of all patients, 25% of patients with tetraplegia). Patients were discharged when the time spent sitting in a wheelchair was 2 × 2 h per day; this occurred after a mean of 100 days (SD = 36). PU recurrence was observed in six cases (18%).

CONCLUSIONS

Our multimodal treatment concept was found to have complication rates comparable to those in the literature; additionally, this approach might be associated with lower recurrence rates with respect to the literature. To reduce high rates of pneumonia occurrence among patients with tetraplegia, preventive measures need to be established. Further evidence of the efficiency of this complex treatment approach for PU in individuals with SCI is needed.

Predictors of pressure ulcer incidence following traumatic spinal cord injury: a secondary analysis of a prospective longitudinal study

STUDY DESIGN

Secondary analysis of data from a prospective cohort study.

OBJECTIVES

The objective of this study was to identify the medical and demographic factors associated with the development of pressure ulcers during acute-care hospitalization and inpatient rehabilitation following acute spinal cord injury.

SETTING

The study was carried out at acute hospitalization, inpatient rehabilitation and outpatient rehabilitation sites at a university medical center in the United States.

METHODS

Adults with acute traumatic spinal cord injury (n=104) were recruited within 24-72 h of admission to the hospital. Pressure ulcer incidence was recorded.

RESULTS

Thirty-nine participants out of 104 (37.5%) developed at least one pressure ulcer during acute-care hospitalization and inpatient rehabilitation. Univariate logistic regression analyses revealed significant association of pressure ulcer incidence for those with pneumonia and mechanical ventilation (P=0.01) and higher injury severity (ASIA A) (P=0.01). Multiple logistic regression showed that the odds of formation of a first pressure ulcer in participants with ASIA A was 4.5 times greater than that for participants with ASIA B, CI (1-20.65), P=0.05, and 4.6 times greater than that for participants with ASIA C, CI (1.3-16.63), P=0.01.

CONCLUSION

Among individuals with acute traumatic SCI, those with high-injury severity were at an increased risk to develop pressure ulcers. Pneumonia was noted to be associated with the formation of pressure ulcers.

Association between presence of pneumonia and pressure ulcer formation following traumatic spinal cord injury

OBJECTIVE

To determine if the presence of pneumonia and pressure ulcers are associated in individuals with an acute spinal cord injury during acute care and rehabilitation hospitalizations.

DESIGN

Retrospective, secondary analyses of data obtained from the Spinal Cord Injury Model Systems enrolled from 1993 until 2006 Setting: Acute care hospitalization and inpatient rehabilitation facilities Participants: A cohort of individuals hospitalized in acute care (n = 3,098) and inpatient rehabilitation (n = 1,768) was included in the analysis. Frequencies of pressure ulcer formation and episodes of pneumonia were noted in both settings.

INTERVENTIONS

Not applicable.

OUTCOME MEASURES

Pressure ulcer formation and diagnosis of pneumonia Results: The development of pressure ulcers, including stage I, was 20.3% acute care and 21.1% during in inpatient rehabilitation. Multivariate logistic regression analyses revealed a significant association of pneumonia with occurrence of pressure ulcers (P ≤ 0.001, OR = 2.3 and 2.2 respectively), the American Spinal Injury Association Impairment Scale grades (P < 0.001), and utilization of mechanical ventilation (P < 0.01) in both settings.

CONCLUSION

A higher presence of pressure ulcers was found in individuals with pneumonia, after adjusting for injury severity, age, sex, and utilization of mechanical ventilation. Impaired inflammatory response and decreased mobility in individuals with pneumonia may predispose these individuals to develop pressure ulcers. Surveillance and preventive measures for pressure ulcers should be rigorous in individuals with SCI and pneumonia.

Use of Noncontact Low-Frequency Ultrasound in Deep Tissue Pressure Injury: A Retrospective Analysis

PURPOSE

The purpose of this study was to examine the effect of noncontact low-frequency ultrasound (NLFU) on deep tissue pressure injury (DTPI), both hospital-acquired and those present on admission (POA).

DESIGN

Retrospective, descriptive study.

SAMPLE AND SETTING

Medical records from 44 adult patients with a DTPI treated with NLFU were reviewed; 22 had a hospital-acquired DTPI (HADTPI) and 22 had DTPI POA. Their mean age was 71.3 ± 16.3 years (mean ± SD); 52% were male. The study setting was a 318-bed community hospital in the Mid-Atlantic region of the United States.

METHODS

Data were collected from the medical records including demographic and relevant clinical characteristics, DTPI measurements, and DTPI evolution/resolution. Data were summarized and examined using descriptive statistics (eg, frequencies and percentages and means and standard deviations). Differences between groups were examined using paired t tests or the Mann-Whitney U test and the chi-square test as appropriate. In addition, the heel DTPI subgroup (N = 8) was examined separately due to the small sample size.

RESULTS

All patients with HADTPI and DTPI POA treated with NLFU exhibited a statistically significant decrease in injury size from initiation to discontinuation of NLFU therapy (24.6 cm vs 14.4 cm, P = .02). No statistically significant difference in wound resolution was found between HADTPI versus DTPI POA (27% vs 18%, P = .47). Mean size of both HADTPI and DTPI POA decreased significantly from 15.9 to 13.4 cm (P = .045) by NLFU therapy. Wounds were classified as resolved at completion of treatment in 23% (10 out of 44) of all treated patients. Of all patients with the potential to be resolved (not discharged early or expired) 63% (10 out of 16) had wounds classified as resolved.

CONCLUSION

Study findings suggest that NLFU is a viable and promising treatment option for both HADTPI and DTPI POA. Future studies are needed to confirm these results and to examine efficacy and feasibility of DTPI across care settings.

Two-stage treatment of ischial pressure ulcers in spinal cord injury patients: Technique and outcomes over 8 years

BACKGROUND

Despite newly introduced techniques, reconstruction of ischial pressure ulcers remains a difficult problem with high-reported failure rates.

METHODS

A retrospective chart review was performed on all spinal cord injury patients who underwent ischial pressure ulcer reconstruction by the senior author (V.L.) between 2004 and 2012. The two-stage procedure consisted of debridement and bone biopsy, followed by bursectomy, partial ischiectomy, fascial release, and gluteus maximus and hamstring advancement flaps. Postoperative care included 2-week supine bed rest on an air-fluidized bed, sitting tolerance rehabilitation, and thorough behavioral training.

RESULTS

Sixty-five patients (74 flaps) were identified. A 45.9% had a previous attempt at reconstruction. The median follow-up period was 622 days. Overall, 67.6% of flaps were intact at the last follow-up. Superficial and deep dehiscence rates were 16.2 and 28.4%, respectively. Seven out of 35 flaps suffered late recurrence after being well healed for more than 1 year. History of previous reconstruction was found to be associated with increased odds of superficial (OR 6.02, 95% CI 1.55-23.3) and deep dehiscence (OR 12.3, 95% CI 1.99-76.9).

CONCLUSIONS

The evolution of the senior author's decades of practice has led to the development of a simpler repair, which relies on plane-by-plane release of scarred tissues to improve the mobility of muscle and skin flaps without large tissue movements, even in the setting of apparent extensive tissue loss. This technique is a reliable option, particularly for the primary ischial pressure ulcer.

Effectiveness of a multi-layer foam dressing in preventing sacral pressure ulcers for the early acute care of patients with a traumatic spinal cord injury: comparison with the use of a gel mattress

Individuals with spinal cord injury are at risk of sacral pressure ulcers due to, among other reasons, prolonged immobilisation. The effectiveness of a multi-layer foam dressing installed pre-operatively in reducing sacral pressure ulcer occurrence in spinal cord injured patients was compared to that of using a gel mattress, and stratified analyses were performed on patients with complete tetraplegia and paraplegia. Socio-demographic and clinical data were collected from 315 patients admitted in a level-I trauma centre following a spinal cord injury between April 2010 and March 2016. Upon arrival to the emergency room and until surgery, patients were transferred on a foam stretcher pad with a viscoelastic polymer gel mattress (before 1 October 2014) or received a multi-layer foam dressing applied to their sacral-coccygeal area (after 1 October 2014). The occurrence of sacral pressure ulcer during acute hospitalisation was similar irrespective of whether patients received the dressing or the gel mattress. It was found that 82% of patients with complete tetraplegia receiving the preventive dressing developed sacral ulcers as compared to only 36% of patients using the gel mattress. Although multi-layer dressings were suggested to improve skin protection and decrease pressure ulcer occurrence in critically ill patients, such preventive dressings are not superior to gel mattresses in spinal cord injured patients and should be used with precaution, especially in complete tetraplegia.

Elevated Levels of Protein Disulfide Isomerase and Binding Immunoglobulin Protein Implicated in Spinal Cord Injury Paraplegia Patients with Pressure Ulcers

AIMS

To explore the associations between two endoplasmic reticulum (ER) stress proteins, protein disulfide isomerase (PDI), binding immunoglobulin protein (BIP), and the development and progression of pressure ulcers (PUs) in spinal cord injury (SCI) paraplegia patients.

METHODS

ELISA kits were used to measure the levels of serum PDI and BIP in 67 SCI paraplegia patients with PUs and 61 SCI paraplegia patients without PUs. The associations between PDI and BIP, PU formation, PU staging, and pressure ulcer scale for healing (PUSH) score were analyzed.

RESULTS

The patients in the PU group had higher levels of PDI and BIP than those in the non-PU group (both p < 0.05). Furthermore, the levels of PDI were positively correlated with those of BIP (r = 0.707, p < 0.0001). There were significant differences in the PDI and BIP levels among the different stages of PU (all p < 0.05). As the PU stages progressed, the levels of PDI and BIP first increased, then decreased, and finally peaked at stage III of the PUs. The PUSH scores significantly declined 7 days after debridement for the PU stage II (p < 0.01) but showed no significant difference between stages III and IV at 7 days after debridement (p > 0.05). The PUSH scores also decreased at 28 days after debridement for stages II, III, and IV (all p < 0.01). Higher PUSH scores indicated a longer time of debridement accompanied by a longer wound surface healing time (p < 0.05).

CONCLUSION

ER stress proteins may be involved in the process of PU formation and healing; moreover, the levels of PDI and BIP were also associated with the severity of the PUs. Finally, we found that the PUSH scores can be used as a reference to evaluate PU severity and healing.

Povezave med razjedo zaradi pritiska in ohranjanjem integritete kože pacienta v intenzivni zdravstveni obravnavi: pregled literature

Uvod: Namen raziskave je prikazati večdimenzionalne potrebe in možne dejavnike tveganja za razjedo zaradi pritiska pri odraslih pacientih v intenzivni zdravstveni obravnavi. Metode: Uporabili smo analizo in sintezo pregleda dokazov iz zbirke podatkov EMERALD, CINAHL, PubMed in ProQuest. Ključne iskalne besedne zveze so bile: »quality of care«, »pressure ulcer«, »prevention and treatment of pressure ulcers«, »skin integrity critical care patients«. Omejitveni kriteriji iskanja so bili: obdobje 2010 do 2013, celotno besedilo člankov v angleščini. Začetna merila je izpolnjevalo 280 zadetkov in 40 izbranih ustreznih prispevkov. Potek raziskave je prikazan v skladu z načeli Cochranove zbirke, ocena kakovosti dokazov pa v hierarhiji dokazov. Rezultati: Identificiranih je 191 kod, ki so združene v 11 vsebinskih kategorij: okolje intenzivne terapije – značilnosti nekaterih dejavnikov tveganja, čas bivanja v enoti, vazoaktivne učinkovine, spol, starost, administrativno diagnostična kategorija, postelja, ležišče, lestvica Waterlow, razjeda zaradi pritiska in pomen prve stopnje razjede. Diskusija in zaključek: Raziskava pokaže pomen uvedbe proaktivnih ukrepov za ohranjanje integritete kože pacienta. Osredotoča se na vitalnost tkiva in promocijo kakovostne zdravstvene oskrbe z vidika teorije. Potrebne so raziskave, ki bi za boljše razumevanje pojasnjevale številna druga tveganja in učinkovite programe za vitalnost kože.

International multidisciplinary consensus conference on multimodality monitoring: ICU processes of care

There is an increased focus on evaluating processes of care, particularly in the high acuity and cost environment of intensive care. Evaluation of neurocritical-specific care and evidence-based protocol implementation are needed to effectively determine optimal processes of care and effect on patient outcomes. General quality measures to evaluate intensive care unit (ICU) processes of care have been proposed; however, applicability of these measures in neurocritical care populations has not been established. A comprehensive literature search was conducted for English language articles from 1990 to August 2013. A total of 1,061 articles were reviewed, with 145 meeting criteria for inclusion in this review. Care in specialized neurocritical care units or by neurocritical teams can have a positive impact on mortality, length of stay, and in some cases, functional outcome. Similarly, implementation of evidence-based protocol-directed care can enhance outcome in the neurocritical care population. There is significant evidence to support suggested quality indicators for the general ICU population, but limited research regarding specific use in neurocritical care. Quality indices for neurocritical care have been proposed; however, additional research is needed to further validate measures.

Surgical Treatment of Pressure Ulcers with a Fibrin Sealant in Patients with Spinal Cord Injury: A Cost-Consequence Analysis

BACKGROUND

A comparative study was performed to evaluate the effectiveness and costs of a fibrin sealant (Tissucol Duo [known as Tisseel in the United States], Baxter International, Deerfield, Illinois) to improve postoperative outcomes in patients with spinal cord injury undergoing surgical treatment for pressure ulcers (PrUs).

METHODS

Between January and June 2011, 27 patients underwent surgical treatment for PrUs with the direct application of Tissucol Duo sprayed before closure. The costs and outcomes obtained in this cohort were compared with those obtained in a previous retrospective study where 71 patients underwent conventional surgery.

RESULTS

Lower rates of hematoma-seroma were observed in the study group (3.7% vs 33.8%; P < .05). Drain removal occurred earlier (10 vs 15 days; P < .05), and the average drain volume was also lower (155 vs 360 mL; P < .05) for this group. The mean length of hospital stay was significantly lower in the study group and was the main contributing factor to the overall costs.

CONCLUSIONS

The application of Tissucol Duo during surgical treatment of PrUs in patients with spinal cord injury has been shown to be effective in reducing postoperative complications and in shortening the duration of the hospital stay with a consequent savings in costs.

Spinal Cord Injury survey to determine pressure ulcer vulnerability in the outpatient population

Pressure ulcers are one of the most common causes of morbidity, mortality and rehospitalization for those living with Spinal Cord Injury (SCI). Literature examining risk and recurrence of pressure ulcers (PrUs) has primarily focused on the nursing home elderly who do not have SCI. More than 200 factors that increase PrU risk have been identified. Yet unlike the elderly who incur pressure ulcers in nursing homes or when hospitalized, most persons with SCI develop their pressure ulcers as outpatients, while residing in the community. The Veterans Health Administration (VHA) provides medical care for a large number of persons with chronic SCI. Included in the VHA SCI model of chronic disease management is the provision of an annual Comprehensive Preventive Health Evaluation, a tool that has potential to identify individuals at high risk for PrUs. This research was motivated by the clinical observation that some individuals appear to be protected from developing PrUs despite apparently 'risky' behaviors while others develop PrUs despite vigilant use of the currently known preventative measures. There is limited literature regarding protective factors and specific risk factors that reduce PrU occurrence in the community dwelling person with chronic SCI have not been delineated. The purpose of this study is to examine the preliminary hypothesis that there are biological and/or psychosocial factors that increase or reduce vulnerability to PrUs among persons with SCI. A limited number of refined hypotheses will be generated for testing in a prospective fashion. A retrospective cross-sectional survey of 119 randomly selected Veterans with SCI undergoing the Comprehensive Health Prevention Evaluation during the year 2009 was performed. Factors that differed between patients with 0, 1 or ⩾2 PrUs were identified and stratified, with an emphasis on modifiable risk factors. Three hypotheses generated from this study warrant further investigation: (1) cumulative smoking history increases the risk of PrUs independent of co-morbidities, (2) being moderately overweight, BMI>25, with or without spasticity, is a modifiable factor that may be protective and (3) increased use of a caregiver does not reduce PrU risk. Prospective studies that focus on these hypotheses will lead to evidence-based risk assessment tools and customized interventions to prevent PrUs in persons with SCI in the outpatient setting.

Impact of pressure ulcers on individuals living with a spinal cord injury

OBJECTIVE

To describe the impact of pressure ulcers on the ability to participate in daily and community activities, health care utilization, and overall quality of life in individuals living with spinal cord injury (SCI).

DESIGN

Cross-sectional study.

SETTING

Nationwide survey.

PARTICIPANTS

Participants (N=1137) with traumatic SCI who were >1 year postinjury and living in the community were recruited. Of these, 381 (33.5%, 95% confidence interval, 30.8%-36.3%) had a pressure ulcer over the last 12 months.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Measures developed for the Rick Hansen Spinal Cord Injury Registry Community Follow-up Survey Version 2.0.

RESULTS

Of the 381 individuals with pressure ulcers, 65.3% reported that their pressure ulcer reduced their activity to some extent or more. Pressure ulcers reduced the ability of individuals with SCI to participate in 19 of 26 community and daily activities. Individuals with 1 or 2 pressure ulcers were more dissatisfied with their ability to participate in their main activity than those without pressure ulcers (P=.0077). Pressure ulcers were also associated with a significantly higher number of consultations with family doctors, nurses, occupational therapists, and wound care nurses/specialists (P<.05).

CONCLUSIONS

Pressure ulcers have a significant impact on the daily life of individuals with SCI. Our findings highlight the importance of implementing pressure ulcer prevention and management programs for this high-risk population and require the attention of all SCI-related health care professionals.

Oral treatment of pressure ulcers with polaprezinc (zinc L-carnosine complex): 8-week open-label trial

Polaprezinc (zinc L-carnosine complex) is a tablet commonly prescribed for gastric ulcers in Japan. Recently, we reported the effects of polaprezinc on pressure ulcer healing at 4-week follow-up. We aimed to further evaluate the efficacy and safety of polaprezinc in 8-week treatment for chronic pressure ulcers. Patients with stage II-IV pressure ulcers for ≥ 8 weeks received 150 mg/day polaprezinc (containing 116 mg L-carnosine and 34 mg zinc) per os for a maximum of 8 weeks. We measured the severity of pressure ulcers weekly using the Pressure Ulcer Scale for Healing (PUSH) score and monitored blood biochemistry. Fourteen patients (nine men; 68.4 ± 11.8 years) were enrolled. Pressure ulcer stages were II (one patient; 7 %), III (nine; 64 %), and IV (four; 29 %). The PUSH score improved significantly from 8.1 [95 % CI, 6.0-10.3] at baseline to -1.4 [-4.0 to 1.1] after 8 weeks (P < 0.001). Differences from baseline were significant after 1 week (P < 0.05). The mean weekly improvement in PUSH score was 2.0. Eleven patients healed within 8 weeks and none dropped out. Serum zinc levels increased significantly (P < 0.001), whereas serum copper levels (P = 0.001) and copper/zinc ratios (P < 0.001) decreased significantly. In one patient, preexisting copper deficiency deteriorated. These preliminary data suggest that polaprezinc may be effective and well-tolerated in 8-week treatment of pressure ulcers and could be a candidate for their oral treatment.

A systematic review and meta-analysis of incontinence-associated dermatitis, incontinence, and moisture as risk factors for pressure ulcer development

The aim of this analysis was to identify the association between incontinence-associated dermatitis (IAD), its most important etiologic factors (incontinence and moisture), and pressure ulcers (PUs). A systematic review and meta-analysis were performed. We searched Medline, Embase, CINAHL, Web of Science, and the Cochrane Library for relevant papers dating through March 15, 2013. Fifty-eight studies were included. Measures of relative effect at the univariate level were meta-analyzed. In most studies (86%), a significant association between variables of interest was found, with pooled odds ratios of PUs in univariate models between 1.92 (95% CI 1.54-2.38) for urinary incontinence and 4.99 (95% CI 2.62-9.50) for double incontinence (p < .05). This evidence indicates an association between IAD, its most important etiological factors, and PUs. Methodological issues should be considered when interpreting the results of this review.

Effects of L-carnosine and its zinc complex (Polaprezinc) on pressure ulcer healing

BACKGROUND

L-carnosine (CAR) is an endogenous dipeptide. We aimed to determine the effects of CAR and its zinc complex polaprezinc (PLZ) on pressure ulcer healing in institutionalized long-term care patients.

METHODS

This study was a nonrandomized controlled trial with a maximum 4-week follow-up. Forty-two patients with stage II-IV pressure ulcers for 4 or more weeks were allocated to 1 of 3 groups in order of recruitment: the control group (n = 14) was untreated, the PLZ group (n = 10) orally received 150 mg/d PLZ (containing 116 mg CAR and 34 mg zinc), and the CAR group (n = 18) orally received 116 mg/d CAR. Pressure ulcer severity was measured weekly using the Pressure Ulcer Scale for Healing (PUSH) score.

RESULTS

At baseline, no significant differences were found among groups in demographic and nutrition parameters and pressure ulcer characteristics (severity, size, and staging). After 4 weeks, the rate of pressure ulcer healing, assessed by the mean weekly improvement in PUSH score, was significantly greater in the CAR (1.6 ± 0.2, P = .02) and PLZ groups (1.8 ± 0.2, P = .009) than in the control group (0.8 ± 0.2). The difference between the CAR and PLZ groups was not significant (P = .73). Actual dietary intakes over this period did not differ significantly among groups.

CONCLUSIONS

Our results suggest that CAR and PLZ may almost equally accelerate pressure ulcer healing during 4 weeks. The results need confirmation by randomized controlled trials with larger sample sizes.